Knock out Fall Incidence
Knock out Fall Incidence作者机构：Ward 53C Department of Internal Medicine Singapore General Hospital 169608 Republic of Singapore Ward 77H Department of Haematology Singapore General Hospital 169608 Republic of Singapore Nursing Division Singapore General Hospital 169608 Republic of Singapore Nursing Quality Department Singapore General Hospital 169608 Republic of Singapore
出 版 物：《Journal of Health Science》 (健康科学（英文版）)
年 卷 期：2014年第2卷第9期
页 面：405-427页
学科分类：12[管理学] 1204[管理学-公共管理] 120402[管理学-社会医学与卫生事业管理(可授管理学、医学学位)] 1004[医学-公共卫生与预防医学(可授医学、理学学位)] 10[医学]
主 题：Falls patient safety quality improvement.
摘 要：Fall is an event in which a person unintentionally descends onto the floor. It may lead to physical injuries, psychological harm and/or financial loses. Over the last three Financial Years 2009-201 l, there had been increasing fall incident rate at the unit level, Department of Internal Medicine and Haematology. The hospital fall performance target was set at 〈 one fall per 1000 patient days. Hence, there was a pressing need for improvement with an emphasis of focused analysis to prevent fall. The aim of the study was to reduce fall incidents by at least 50% at W53C and W77H in Financial Year 2012. The baseline fall incident data was collected from February 2011 to March 2012 for both wards. A total number of 33 falls with a median of 2.5 and 1.1 falls per 1000 patient days respectively were collected. The verification of root causes to fall incidences was identified in Pareto Chart. The 3 root causes were： Delayed elimination round, underestimated patients＇ risk for falls and lack of care coordination among team members. The solution implementations were： Cessation ofhardcopy of elimination chart and daily assessment of patient＇s fall risk using modified Morse Fall Scale was changed from paper to electronic. Conducting root cause analysis post fall and sharing near miss incidences were another two implementations to draw the learning points from the incidents to prevent the similar occurrence. Reallocation of staffassignment without increasing manpower to ensure better care coordination was the 5th solution. With the above stated multi-factorial interventions, a significant fall incidence rate was achieved. It had achieved 7% more than the target set for the project.
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